ORIGINAL PAPER

International Journal of Occupational Medicine and Environmental Health 2016;29(1):5568

http://dx.doi.org/10.13075/ijomeh.1896.00512

BYSSINOSIS AND COPD RATES AMONG FACTORY

WORKERS MANUFACTURING HEMP AND JUTE
MUKREMIN ER1, SALIH A. EMRI2, AHMET U. DEMIR2, PETER S. THORNE3, YALCIN KARAKOCA4,
NAZMIBILIR5, and IZZETTIN Y. BARIS 2
1
Ataturk Training and Research Hospital, Ankara, Turkey
Pulmonary Diseases Department
2
Hacettepe University, Ankara, Turkey
Faculty of Medicine, Department of Pulmonary Diseases
3
University of Iowa, Iowa City, USA
Department of Occupational and Environmental Health, Environmental Health Sciences Research Center
4
Istanbul Medical Park Hospital, Istanbul, Turkey
Department of Pulmonary Diseases and Interventional Bronchology
5
Hacettepe University, Ankara, Turkey
Faculty of Medicine, Department of Public Health

Abstract
Objectives: Prior studies have been performed on cotton textile plants throughout theworld. This study was planned to
identify therate of byssinosis and chronic obstructive pulmonary disease(COPD) in hemp and jute workers and those who
worked with both of them. Material and Methods: Thestudy was realized in afactory which consecutively processed hemp
and jute. The study enrollment included266people,164ofwhom were active workers and102were retired. Aquestion-
naire, plain chest X-rays, physical examination and pulmonary function tests were performed. Dust levels were measured in
various sections of thefactory during8h work shifts. Endotoxin levels of various quality hemp fibers and dusts were mea-
sured. Results: Therate of byssinosis(28.2%) was higher among theworkers that who exposed to both jute and hemp dust.
Thefrequency of chronic bronchitis in retired workers who previously smoked was higher(20%) as compared to currently
smoking workers(17%). High dust levels were measured in some parts of thefactory (mean(M) =2.69mg/m3). Working
in dense dust areas, active smoking, being older than40years of age, being an ex-smoker, and working in thefactory for
aperiod exceeding15years were significantly associated with bronchitis and emphysema development. High endotoxin
levels were determined for fine hemp dust (605EU/mg), coarse hemp dust(336EU/mg) and poor quality hemp fibers
(114EU/mg), whereas in fresh hemp stalks thelevel of endotoxin was determined to be lower(0.27EU/mg). Conclusions:
Because of high exposures to jute and hemp dusts that are associated with high byssinosis rates, personal protection and
environmental hygiene is crucial to prevention of byssinosis.

Key words:
Byssinosis, Endotoxin, COPD, Hemp, Jute, Occupational health

Received: November 18, 2014. Accepted: March 4, 2015.

Corresponding author: M. Er, Ataturk Training and Research Hospital, Pulmonary Diseases Department, 06800Bilkent, Ankara, Turkey (e-mail:
mukreminer@hotmail.com).

Nofer Institute of Occupational Medicine, d, Poland 55

 ORIGINAL PAPER M. ER ET AL.
INTRODUCTION
It is known that exposure to theorganic dusts of textile
plants results in respiratory system complaints and pul-
monary diseases like byssinosis, chronic bronchitis, asth-
ma-like syndrome, reactive airway dysfunction syndro
me(RADS), occupational asthma and emphysema[14].
The1stscholar to draw attention to occupational diseas-
es and byssinosis was theItalian physician, Bernardino
Ramazzini in the17thcentury. Ramazzini in his book
De morbis artificum diatriba detailed the relation-
ship between occupation and diseases[5]. With theon-
set of theindustrial revolution, from the2ndhalf of
the19thcentury, increased production in thetextile sec-
tor resulted in augmentation of occupational diseases.
In1936, Prausnitz, aBritish physician, drew attention
to byssinosis and, in1950 Schilling provided adetailed
description[6,7].
Byssinosis wasfirstdefined in cotton workers, but in later
studies it was also shown in workers who inhaled thedust
of hemp, flax, sisal, jute and other fiber plants [810].
Byssinosis has been studied mostly in cotton workers, but
there have also been several studies performed among
hemp and jute workers [1118]. Eastern European data
from the1970s and1980s described byssinosis frequen-
cyas4766% in people inhaling hemp dust[11,12].
Byssinosis is the most known and specific work-related
illness in thetextile sector. Theclassic symptoms of bys-
sinosis consist of fever, malaise, chest tightness and dys-
pnea. Symptoms in theearly stages of thedisease occur
on Monday, after theweekend vacation. Previously it was
called Monday Fever but in 1956 it was described as
stage1byssinosis by Schilling, and asB1 in therevised bys-
sinosis stages by the World Health Organization(WHO)
andthe U.S.National Institute for Occupational Safety
and Health(NIOSH). At theearly stage of byssinosis(B1)
symptoms of chest tightness, fever and malaise are only
seen on the1stworking day (Monday) and disappear in
thefollowing days. In the2ndstage of thedisease, defined
56 IJOMEH 2016;29(1)
asB2, thesymptoms expand to other days of theweek and
progress apart from work. With theprogression of thedis-
ease, permanent changes like chronic bronchitis and em-
physema develop in theworkers producing restriction in
their effort capacity and decrease in quality of life attrib-
utable to respiratory failure. Respiratory system irritation
symptoms and pulmonary function test parameters are
also rated inthe WHO classification[18,19].
Diseases related to chronic bronchitis and local irritation
symptoms (nasal, ocular), are seen more often in people
who inhale thedusts of hard textile plants like jute and
sisal than soft textile plants like cotton and hemp[13]. In-
haling jute dust results in chronic bronchitis, cough and
wheezing whereas byssinosis frequency is quite low [13
17]. On theother hand, theincrease in byssinosis is seen
when exposure to jute dust is accompanied by exposure to
other plant dusts[20,21].
Etiopathogenesis of byssinosis and other respiratory sys-
tem diseases caused by organic plant dusts arise princi-
pally from endotoxinsfromthecellwallofGramnega
tivebacteria[2226].
Now, we know that endotoxins are major etiologic fac-
tor over developing byssinosis and other respiratory dis-
eases. Myriad studies show that endotoxin exposure has
acausal role over developing byssinosis. According to
them, Monday sickness has been correlated with airborne
endotoxinconcentrations, but not exactly correlated with
airborne dust concentrations.
Some studies respected those acute alterations in lung
functions over thecourse of aMonday work-shift and sig-
nificant correlation with airborne endotoxins. Previously,
while byssinosis had been thought that restricted to work-
ers with exposure to cotton, flax and hemp dust, similar
effects among workers inhaling endotoxin contaminated
dust in wool carpet factories, swine confinement centers,
and animal feed mill facilities have been found in some
studies. Also, endotoxin has apossible role in theetiology
of hypersensitivity pneumonitis[23].

Another study revealed that past exposure to endotoxin
was associated with reduced forced expiratory volume
in1s(FEV1)level among retired cotton workers. More-
over, past exposure was more strongly associated with
reducedFEV1 for those hired<5years before baseline
than for those who were hired 5 years after baseline.
Thestudy showed that recent endotoxin exposure was
significantly associated with byssinosis, chronic bronchi-
tis,and chronic cough[24].
In astudy, in which animal model rat has been used to
assess theeffects of occupational stresses and hazards on
exposure to textile environment, theinvestigators of the
study showed increased- and -globulins and decreased
total proteins and albumin levels. Also, they found in-
creased serumC-reactive protein levels. They suggest that
inhaled particles in thetextile environment have extrapul-
monary activity besides thepulmonary effects[25].
Manufacturing of rope, cord and hawser from hemp may
be seen in various parts of Turkey, especially in Western
Anatolia and the Black Sea region. People often do this
job from childhood in workshops without ventilation sys-
tems with substantial inhalation of hemp dust. Jute is afi-
brous textile plant grown in India, Bangladesh and neigh-
boring countries. It is one of thecheapest natural textile
fibers and has the2ndhighest consumption in theworld
after cotton.
Cotton based textile manufacturing is one of theimpor-
tant industries in Turkey. Much more epidemiological
studies have been made on thediseases caused by cotton
dusts among textile workers in Turkey. The1stof these
studies performed in Turkey was made by Tokgoz in1968
among cotton workers, but no Turkish study has been done
regarding other plant dusts that cause byssinosis[2630].
Our study was conducted in theonly jute processing facto-
ry in Turkey, where unprocessed jute fibers that came from
Bangladesh were turned into rope used for thebacking of
synthetic carpets, sackcloth, cord and hawser. Thefactory
was established to process hemp fibers in1947. In1983,
BYSSINOSIS AND COPD RATES IN HEMP AND JUTE WORKERS ORIGINAL PAPER
processing machinery was renewed to handle jute plants
imported from Bangladesh. Our study was conducted dur-
ing theprocessing of jute. This factory was selected to re-
search theeffects of both plants on therespiratory system
and byssinosis prevalence among theworkers.
This study is the1stin Turkey that covers theoccupational
exposure in jute and hemp workers. We performed this
study among thecurrent and retired workers of this jute
rope factory which processed hemp in thepast, to assess
thefrequency of byssinosis and other airway diseases,
therole of dust concentrations in respiratory tract symp-
toms and developed occupational lung diseases. In addi-
tion, endotoxin levels were measured for various quality
hemp fibers and dusts to assess therole of endotoxins on
thedevelopment of byssinosis.
MATERIAL AND METHODS
Study design
Across-sectional survey was conducted in afactory ma
nufacturing rope made of jute. Thestudy was carried out
between April1997 and August1998. Aresearch team
measured dust levels in thefactory, administered ques-
tionnaires for workers and acontrol group, made physi-
cal inspections and chest X-rays, performed respiratory
function tests and data analysis. This study was conduct-
ed in atextile factory located at Taskopru Province of
Kastamonu City at theNorthern Anatolia region of Tur-
key. Some workers of thefactory working in jute process-
ing also worked previously in processing hemp.
The factory was established for hemp processing in1947
and continued till1983, but as themachinery became
old-fashioned, they were renewed to process jute plant
imported from Bangladesh. Our study was done dur-
ing this period. Thefactory ended its production in2004
and moved to anew factory in Gaziantep. Thus, current
working environment and thedust concentrations are not
thesame, so that it could not be known, whether or not
thepresented data is still applicable and valid.
IJOMEH 2016;29(1) 57
 ORIGINAL PAPER M. ER ET AL.
The goal of this study was to understand theeffect of hemp
dust and jute dust together and separately on theworkers
of thefactory as well as theappearance of byssinosis fre-
quency and other chronic pulmonary diseases when these
dusts are inhaled over along period of time.
Study population
This study was conducted in ajute rope factory on164cur-
rent workers and102retired workers. Among current
workers,19had also worked in hemp processing be-
fore1983,60ofthem started working after1983 and nary function tests. Measurements were taken by using
were exposed only to jute dust,78ofthem worked both in
hemp and jute processing and were exposed to both dusts,
and7had no dust exposure. Seventy-nine of thecurrent
workers were employed in high dust concentration areas
according to our measurements including in thestock
room, bundle opening and spreading, carding, wind-
ing and spinning sections (Photo1). Fifty-one worked in
low dust concentration areas including drawing, beaming
and threading sections. Eight sections of thefactory were
characterized as follows:
storage (stock room),
bundle opening and spreading,
softening,
carding (breaker carding and finisher carding),
drawing (thinning),
spinning,
winding,
beaming (threading).
Data collection
Questionnaires
Aquestionnaire published by Rylander for evaluation of
organic dust exposure was administered to both current
and retired workers[31]. This questionnaire ascertained
work history, respiratory system complaints and smoking
status. Byssinosis symptoms for retired workers were as-
certained from self-reporting of their past experiences.
58 IJOMEH 2016;29(1)
Physical examination
Participants of thestudy went through an overall physi-
cal inspection especially on therespiratory system. Par-
ticipants were checked for wheezing, any increase in their
anterior-posterior chest diameter, intercostal retraction,
cyanoses, percussion hyper-resonance and rhonchi were
noted.
Pulmonary function tests
All theparticipants in thestudy went through pulmo-
aVitalograph/Compact (England) spirometer. Thespi-
rometer was calibrated before pulmonary function tests.
Participants age, height and sex were noted. Each par-
ticipant underwent3measurements and thebest value
was noted. Forced vital capacity(FVC), forcedexpi-
ratoryvolume in1s(FEV1), forced vital capacity/forced
expiratory volume in1s(FEV1/FVC), peak expiratory
flow rate (PEFR), maximal mid-expiratory flow ra-
te (MMEFR)weremeasured.
Chest X-rays
All participants posterior-anterior(PA) chest X-rays were
evaluated by2different physicians according tothe 1980
International Labor Organization(ILO) pneumoconiosis
assessment standards. Radiography findings like hyper-
lucency, diaphragm flattening, and emphysema presence
were especially noted.
Working environment dust measurement
Ankara Occupational Health and Safety Center per-
formed dust measurements in different parts of thefac-
tory during this study. Altogether 7dust measurements
were performed. Avertical elutriator operated at aflow
rate of7.40.2l/min was used to measure theconcen-
tration of thedust in theareas of theworkers. To col-
lect thedusts inside of thevertical elutriator, Sartorius
cellulose nitrate filters with pore diameter of5m were

a)
c)
Photo1. Dusty sections of thefactory: a) opening and spreading, b) softening, c) carding, d) spinning
used. Dust concentrations were measured gravimetri-
cally using acalibrated microbalance. As there are no
accepted specific occupational exposure limits (OEL)
in theworld for hemp and jute dusts, the8-h time-
weighted average, permissible exposure limit(PEL)
from theUSOccupational Health and Safety Adminis-
tration(OSHA) for cotton dust of0.2mg/m3 was selec
tedasan acceptableOEL[3234].
Endotoxin level measurements
Higher rates of byssinosis were determined in work-
ers exposed to hemp dust, when compared to workers
exposed to jute dust. We hypothesized that these might
BYSSINOSIS AND COPD RATES IN HEMP AND JUTE WORKERS ORIGINAL PAPER
b)
d)
have been be due to ahigh endotoxin content of various
parts of hemp and processed hemp dust. Thus, endotoxin
measurements were conducted to investigate certain com-
ponents of thehemp plant. Air sampling filters were not
available for analysis of endotoxin. Thus, dust samples
were taken from anearby workshop, because thejute fac-
tory did not process hemp at that time. Endotoxin levels
were measured in processed and unprocessed hemp plants
and in hemp dust.
Endotoxin concentrations in thedust were mea-
sured using theLimulus Amebocyte Lysate as-
say(QCL-1000LALAssay, Lonza,Inc.) performed
as previously described [35]. Samples were eluted into
IJOMEH 2016;29(1) 59
 ORIGINAL PAPER M. ER ET AL.

pyrogen-free water, were shaken for60min at room Table1. Airborne dust concentrations measured in thesections
of thefactory
temperature and assayed against the Control Standard
Endotoxin(EC-6U.S.FDAStandard). Factory section
Dust concentration
[mg/m3]
Opening and spreading 1.80*
Statistical analysis
Carding
Epi Info6.04 was used for basic statistical calculations.
finisher carding 2.69*
For logistic regression calculations, WindowsSPSS17.0 breaker carding 0.98*
software was used. To examine thestatistical significance Winding 2.41*
of thedifferences among theresults obtained from differ- Spinning 0.97*
ent groups, we usedChi2 test for theanalysis of groups Drawing 0.06
with more than10samples and Fishers exactChi2 test Beaming and threading 0.10
for theanalysis of groups with fewer than10samples. *Dust concentration higher than theU.S.Occupational Health and
A p < 0.05 was used to determine significance of find- Safety Administration(U.S.OSHA) permissible exposure limit(PEL)
of0.2mg/m3.
ings. Therisk of getting chronic respiratory tract diseases
caused by exposure to hemp and jute dust together or
Table 2. Endotoxin concentrations in various quality hemp
solitarily was calculated using logistic regression analysis dusts and fibersa
by considering various factors like age, sex and smoking
Endotoxin content
habit. Relative risks and odds ratios are presented along Sample description
[EU/mg]
with95%confidence intervals(CI). Coarse hemp dust 336.00
Fine hemp dust 605.00
RESULTS Hemp fiber quality
Dust measurements good 27.70
Airborne dust measurements were made in various sec- fair 47.00
tions of thefactory. In most of these sections, dust lev- poor 114.00
Hemp stalk 0.27
els were considerably higher than theU.S.OSHA occu-
Dried hemp leaves 11.10
pational exposure limit of0.2mg/m3. High levels of dust
concentration were found especially in bundle opening a
Samples for endotoxin analysis were obtained from multiple sections
of factory while processing hemp.
and spreading, carding, winding and spinning sections. In
drawing, beaming and threading sections, dust concentra-
tions were below theOEL (Table1). observed in carding would suggest an extremely high en-
dotoxin exposure level of1600EU/m3.
Endotoxin level measurement findings
High levels of endotoxin were detected especially in fine Findings related to study population
hemp dust(605EU/mg), coarse hemp dust(336EU/mg), This study was carried out on atotal of266employees of
poor quality hemp fibers(114EU/mg), and lower levels the jute processing factory, including77females(29.3%)
in fresh hemp stalks(0.27EU/mg) (Table2). Endotoxin and189males(70.7%). One hundred sixty-four par-
levels in jute plant and jute fiber dust were not assessed. ticipants(118male and46female) were active work-
Exposure to fine hemp dust at the mean exposure level ers,102participants(71male,31female) were retired

60 IJOMEH 2016;29(1)
 BYSSINOSIS AND COPD RATES IN HEMP AND JUTE WORKERS ORIGINAL PAPER

workers. There was no difference between groups in terms
of gender. As expected, theaverage age of retired work-
ers was higher and they were shorter. When acomparison
is made regarding smoking habits,76(46.3%)of theac-
tive workers and57(55.9%)ofretired workers have never
smoked. Percentage of participants who quit smoking
was higher in theretired employee group. Percentage of
current smokers among active workers(39%) was signifi-
cantly higher than retired workers(18.6%). Approximate
pack-years of smoking were higher for active smokers and
ex-smokers of theretired workers group (Table3).
When active workers and retired workers are classified in
terms of type of dust exposure, most of theactive workers
were exposed to jute alone and hemp plus jute in contrast
with retired workers who were mostly exposed to hemp
alone with fewer exposed to hemp plus jute. Although
therate of using adust mask was low in both groups,
nearly3-times as many retired workers as current work
ersreported any use(30.4% vs.11.6%) (Table3).
Pulmonary function test results of current and retired
workers according to smoking status are presented in
Table3. As one would expect, thepulmonary function

Table3. Thedemographic characteristics and status of habits of study participants

Current workers Retired workers Total

Variable
(N=164) (N=102) (N=266)
Gender[n(%)]
females 46(28.0) 31(30.4) 77(29.3)
males 118(72.0) 71(69.6) 189(70.7)
Age[years](MSD) 40.73.9 61.110.3 48.212
Height[cm](MSD) 165.28.0 158.25.5 162.77.9
Working period[years](MSD) 16.73.6 21.15.2 18.15.2
Smoking status[n(%)]
never smoked 76(46.3) 57(55.9) 140(50.0)
former smoker 24(14.6) 26(25.5) 53(18.9)
current smoker 64(39.0) 19(18.6) 87(31.1)
Amount of smoking[pack-years] (MSD)
a

former smoker 18.413.5 41.338.6 29.130.7

current smoker 25.311.9 52.047.5 32.127.2
Dust exposure[n(%)]
hemp dust 19(11.6) 61(59.8) 80(28.6)
jute dust 60(36.6) 7(6.9) 67(23.9)
hemp and jute dust 78(47.6) 27(26.5) 105(37.5)
no dust exposure 7(4.3) 7(6.9) 28(10.0)
Usage of dust mask[n(%)]
never 145(88.4) 71(69.6) 216(82.2)
seldom 13(7.9) 16(15.7) 29(13.2)
frequent 6(3.7) 15(14.7) 21(4.6)

M mean; SD standard deviation.

a
Pack-year=daily smoked packs of cigarette smoked years.

IJOMEH 2016;29(1) 61
 ORIGINAL PAPER M. ER ET AL.

parameters were worse in smoking and retired workers Table5. Comparison of byssinotic complaints of workers who
work at sections with high density of dust and sections with low
(Table4). Overall, retired workers hadFEV1 andFVCval- density of dust
ues lower by8% of predicted values than those currently
employed. Importantly, there was a9.2%loss ofFVC Workers group work
conditions
and7.7%loss ofFEV1 among current workers who never Byssinotic sign [n(%)] p
smoked. Chest tightness and arthralgia were significantly high dusta low dustb
greater in workers employed in relatively dusty environ- (N=79) (N=51)
ments than those in low dust areas. Chest tightness 24(30.3) 4(7.8) 0.01
All byssinotic complaints were more frequent in more Dyspnea 12(15.1) 2(3.9) 0.01
highly exposed workers with significant differences seen Wheezing 5(6.3) 1(1.9) 0.07
for chest tightness, dyspnea, cough, lassitude and joint Cough 21(26.5) 5(9.8) 0.01
pain (Table5). Fever 6(7.5) 2(3.9) 0.06
Furthermore, feelings of tickling in thethroat, nose itch- Lassitude 15(18.9) 3(5.8) 0.02

ing, sneezing and local irritation symptoms such as skin Joint pain 12(15.1) 1(1.9) 0.01
Headache 16(20.2) 9(17.6) 0.55
itching were significantly higher in workers in high dust
Nausea 4(5.0) 1(1.9) 0.08
work areas (Table6). Byssinosis symptoms for current
workers exposed to hemp plus jute dust were signifi- a
Sections with high dust are stock room, opening and spreading, card-
ing (breaker carding, finisher carding), winding and spinning.
cantly higher when compared to workers exposed only to b
Sections with low dust are drawing, beaming and threading.
jute dust. Theprevalence of byssinosis symptoms among
theretired workers with combined exposure to hemp and Table6. Comparison of local irritation symptoms of workers
jute was twice as high as jute-only exposed retired work- who work at sections with high concentrations of dust and
sections with low concentrations of dust
ers, however, this difference did not reach significance
Workers group work
Table4. Thepulmonary function test parameters conditions
oftheworkers Local irritation [n(%)] p
symptoms
Smoking status high dusta low dustb
[%] (N=79) (N=51)
PFT Throat tickling 19(24.0) 3(7.8) 0.01
current workers retired workers
parameter
(N=164) (N=102) Nasal itching and sneezing 18(22.7) 2(3.9) 0.01
NS ES CS total NS ES CS total Eye burning 11(13.9) 3(5.8) 0.03
FVC 90.8 87.2 85.2 87.7 87.4 79.2 73.6 80.0 Skin itching 15(18.9) 1(1.9) 0.01
FEV1 92.3 88.0 84.4 88.2 86.2 80.4 75.0 80.5 a, b
As in Table 5.
FEV1/FVC 80.2 78.1 77.7 78.6 79.5 75.7 73.4 76.2
PEFR 91.1 83.4 83.9 89.0 86.9 83.0 73.6 81.1 due to low numbers of retired workers with combined ex-
MEF2575 93.5 88.9 87.2 88.3 89.3 81.1 78.7 83.0 posure (Table7).
PFT pulmonary function test; FVC forced vital capacity; FEV1
A significant relationship was found between chronic
forced expiratory volume in1s; FEV1/FVC ratio of forced expiratory bronchitis, development of emphysema and risk factors
volume in1s and forced vital capacity; MEF2575 maximum expiratory
flow at2575%; % percent predicted.
such as working in high dust environments, being asmok-
NS never smoked; ES ever smoked; CS current smoker. er, being an ex-smoker, or working at this environment

62 IJOMEH 2016;29(1)
 BYSSINOSIS AND COPD RATES IN HEMP AND JUTE WORKERS ORIGINAL PAPER

Table7. Chronic diseases prevalence of current and retired workers according to dust exposure and smoking status

Current workers exposure Retired workers exposure

[n(%)] [n(%)]
Disease jute dust hemp and jute dust jute dust hemp and jute dust
NS ES total NS ES total NS ES total NS ES total
(N=23) (N=37) (N=60) (N=42) (N=36) (N=78) (N=25) (N=36) (N=61) (N=14) (N=13) (N=27)
Byssinosis 3(13.0) 2(5.4) 5(8.3) 10(23.8)* 12(33.3)* 22(28.2)* 5(20.0)* 7(19.4) 12(19.6) 6(42.8)* 5(38.4)* 11(40.7)*
Chronic 0(0.0) 4(10.8) 4(6.6) 2(4.7) 8(22.2)* 10(12.8) 1(4.0) 6(16.6)* 7(11.4) 2(14.2) 3(23.0)* 5(18.5)*
bronchitis
Emphysema 1(4.3) 4(10.8) 5(8.3) 2(4.7) 5(13.8)* 7(8.9) 4(16.0) 6(16.6)* 10(16.4)* 1(7.1) 4(30.7)* 5(18.5)*

NS never smoked; ES ever smoked.

* p<0.05. Comparison of statistical significance was computed only amongst current workers in the same dust exposure category and who have the
same current smoking status.

Table8. Logistic regression analysis showing odds ratios(OR) for association between dust exposure in theworkplace, smoking
andother confounding risk factors with chronic bronchitis, emphysema and byssinosis

Disease
Risk factor OR(95%CI)
chronic bronchitis emphysema byssinosis
Being a current worker 0.38(0.091.62) 0.40(0.101.60) 0.47(0.063.52)
Being a retired worker 0.65(0.161.98) 0.62(0.182.15) 0.89(0.136.28)
Employed in theworking place >15years 2.30(1.114.77)* 3.87(1.708.90)* 3.39(1.447.80)*
Hemp dust exposure 1.06(1.031.08)* 2.69(1.176.21)* 2.47(1.085.67)*
Current smoking 0.83(0.174.02) 0.61(0.162.50) 0.71(0.172.94)
Past smoking history 2.06(1.063.97)* 1.44(0.365.70)* 0.80(0.115.93)
Working in the section with high dust 0.66(0.291.48) 2.50(0.4414.14)* 4.74 (0.5143.98)*
Working in the section with high dust and smoking 6.10(1.1731.65)* 11.97(1.9972.42)* 8.88(1.4056.37)*

OR odds ratio; CI confidence interval.

* High risk.

more than15years. Asignificant relationship was found
between thedevelopment of byssinosis and factors such
as being an active worker plus smoker, being aretired
worker plus ex-smoker and working at thefactory more
than15years and being exposed to hemp dust (Table8).
DISCUSSION
Firstly, Prausnitzs and then Schillings epidemiological
study in England in1950 determined that about1/2of
thecotton workers had byssinosis, whereas todays studies
show that this rate is reduced to 3% [6,7]. Research in
Turkey has shown that byssinosis frequency in cotton work-
ers is about1516%[2630]. Although byssinosis preva-
lence among cotton workers in Turkey has not fallen, as
in more developed countries, with necessary precautions
adecreasing trend is noticed. As far as we know, no prior
research was made in Turkey to determine lung diseases
among workers exposed to hemp and jute dust.
Most published studies about therespiratory diseases
caused by plant dusts have been performed among cotton

IJOMEH 2016;29(1) 63
 ORIGINAL PAPER M. ER ET AL.
workers and few have addressed respiratory tract dis-
eases from hemp and jute. In a1996 study made by Fish-
wicketal., respiratory complaints were determined in64%
of hemp workers[9]. In theresearch of Zuskinetal., bys-
sinosis frequency in hemp workers was found as4766%,
especially higher in smokers[12].
In thefactory where we carried out our study, byssinosis
frequency among retired workers was recorded as26.2%.
Since we diagnosed byssinosis among retired workers
according to their old respiratory system symptoms we
might have determined alower rate of byssinosis as com-
pared to Zuskins study. Our determination according to
results of logistic regression analysis was that byssinosis
risk is increased4.74times in retired smokers as compared
to current workers,3.39times in workers employed in
thefactory more than15years as compared to shorter
duration-employed workers, and2.47times in workers
exposed to hemp dust compared to workers who were
exposed to jutedust.
In radiological and physical examination of retired hemp
workers, emphysema was detected at around26.2%.
This percentage was27.7%insmokers and24%in non- ers exposed to hemp or jute dust were detected, which
smokers. Logistic regression analysis indicated that ex-
posure to hemp dust may cause emphysema with an odds
ratio of2.69. Working in thefactory more than15years
increased therisk of emphysema3.87times, whereas in
retired workers, being exposed to hemp dust and smoking,
increased this risk2.5times. In aprevious study, it was
claimed that therate of emphysema did not increase
among cotton workers[20]. In our study, we determined
emphysema in nonsmoking workers as well.
Worldwide studies of respiratory system diseases caused
by exposure to jute dust figure that chronic bronchitis,
coughing and wheezing frequency are found at thesame
rates as with the exposure to other fiber structured tex-
tile plants like cotton and hemp, whereas byssinosis fre-
quency is lower. On theother hand, byssinosis frequency
is higher when exposure to jute dust is present with other
64 IJOMEH 2016;29(1)
plant dusts[21]. In these studies it is also noted that chron-
ic bronchitis, nasal and ocular irritation are on thefront
burner in the workers who inhaled the dusts of hard fi-
bered textile plants like jute and sisal[13].
The results of this study are consistent with theresults in
these earlier studies. We found that average byssinosis
rate in theworkers who are exposed only to jute dust
is8.3%, whereas in thejute workers who also worked
in hemp processing therate is higher(28.2%). Thecom-
plaints related to local irritation were more common in
theworkers employed in high dust sections like open-
ing, spreading, ruffer and bobbin as compared to work-
ers exposed only to jute dust. Thedifference between
theworkers in thelow and high dust sections was statisti-
cally significant.
The rates of byssinotic complaints and chronic bronchi-
tis were higher among thesmoking workers. According
to results of thelogistic regression analysis, working in
high dust sections and smoking at thesame time increase
chronic bronchitis risk6-fold. Whether retired or active,
more respiratory system complaints in smoking work-
confirms previous studies showing theadditive effect of
plant dusts with smoking in textile workers. Smoking re-
sults in increased risk for byssinosis caused by prolonged
exposure to plant dusts like cotton, hemp and flax and
also leads to nasal cancer caused by exposure to wood
dust[36]. In order to avoid an additional risk from oc-
cupational exposures, workers should be encouraged not
to take up smoking or to quit smoking if they already
smoke. With theprecautions in developed countries,
byssinosis and its advanced stage chronic obstructive
pulmonary disease(COPD) seen in textile workers in
cotton mills, is showing adecreasing trend, whereas in
Turkey this is still an important problem in textile work-
ers processing fiber plants apart from cotton. Installa-
tion of engineering controls to decrease dust concentra-
tions in textile-production factories should be taken as

soon as possible and workers should be provided with
respirators and aproper respiration fit program for fur-
ther protection[37].
Although we observed lower byssinosis frequencies among
workers exposed to only jute dust compared to only hemp
dust and hemp dust plus jute dust, high rates of eye, nose
and skin irritation symptoms were seen in current work-
ers exposed to jute dust. This situation may arise because
jute is ahard structured fiber as compared to cotton and
hemp fibers. Jute fibers are less likely to reach thelower
respiratory tract because most deposit in thenasal ca
vityand pharynx. Hence we encountered more local irrita
tionsymptoms of theupper respiratory tract and eyes.
The rate of emphysema and chronic bronchitis, which
are components ofCOPD, is more common among
current or former smoker workers compared to never
smoker workers. We found higher byssinosis prevalence
in individuals who inhaled hemp dust. This can be ex-
plained by thehigher endotoxin content of hemp. To
prove thepresence of emphysema in these workers,
further studies using more sophisticated investigation
tools including diffusion testing, static lung volume
measurements and high resolution computed tomogra-
phy(HRCT) are needed.
We found that endotoxin levels were very high in dust
taken from many areas of thehemp factory with mean air
concentrations expected to exceed100EU/m3. This signifi-
cantly exceeds therecommendedOELs of50EU/m3 from Turkey. Controlling byssinosis disease, which is threaten-
theNetherlands. These findings support previous studies
about therelation of endotoxins and byssinosis[2225,38].
Our findings also suggest that advanced stage byssinosis
may lead to development of chronic bronchitis and em-
physema which are both components ofCOPD.
The study has shown that byssinosis prevalence is higher
in hemp workers, perhaps due to higher endotoxin con-
tent of hemp fibers. To thebest of our knowledge, no prior
study revealed ahigher byssinosis prevalence in hemp
workers. In older studies, Schwartzetal. showed that
BYSSINOSIS AND COPD RATES IN HEMP AND JUTE WORKERS ORIGINAL PAPER
tumor necrosis factor (TNF-), interleukin-6(IL-6) and
other cytokines were higher in nasal lavage fluid of mice
exposed to grain dust [39]. Also, Shvedova et al. found
that cotton dust induced elevated levels ofIL-6, interfer-
on(INF-) andTNF- in bronchoalveolar lavage(BAL)
fluid of mice[40]. Therefore, there is anecessity to per-
form further investigations with hemp dust on animals or
humans, including evaluation of biomarkers of inflamma-
tion inBALfluids, to clarify higher byssinosis prevalence
in hemp workers.
Limitations of our study
We examined thepulmonary functions of workers by spi-
rometry only once, unfortunately we could not measure
before and after thework shift. In addition, we could not
prove emphysema of theworkers by thoracic high resolu-
tion computed tomography due to technical insufficiency.
Also, we could not perform theroutine blood tests of
theworkers.
CONCLUSIONS
Byssinosis is no longer aproblem in most developed
industrial countries due to theinstitution of strict oc-
cupational health standards and theexportation of jobs
in thetextile industry to developing countries. As an
agricultural and industrial country, about1/2million
workers are presently engaged in thetextile sector in
ing thehealth of workers in Turkey, will increase thepro-
ductivity in manufacturing and also contribute to over-
allhealth in Turkey.
ACKNOWLEDGMENTS
We would like to thank Assoc.Prof. Ali Naci Yildiz,M.D. for
advice on statistical points of survey and also thank Nurten Er-
dem,Ph.D. fromISGUM (National Institute of Occupational
and Safety of Health Administration of Turkey) for conducting
dust measurements in thefactory.
IJOMEH 2016;29(1) 65
 ORIGINAL PAPER M. ER ET AL.
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